Counseling Form

First Name*
Last Name*
Email Address*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Full Name of Child Diagnosed with Cancer/LCH/HLH/Aplastic Anemia*
Date of Birth*
Date Format: MM slash DD slash YYYY
Diagnosis / Type of Cancer*
Date of Diagnosis*
Date Format: MM slash DD slash YYYY
My child is:*
- On Active Treatment
- Has Completed Treatment
- Deceased
Name of family member for whom you are seeking therapy*
By submitting this form, I give CURE Childhood Cancer permission to provide my name, contact information, and limited health information regarding the child with cancer to the Providers providing counseling services. By submitting I am also stating that I have read and understand these Guidelines and the Disclaimer provided above.*
- I Consent (Please check box giving consent)